Provider Demographics
NPI:1457705956
Name:JACKSON CULLISON, STEPHANIE RENAE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENAE
Last Name:JACKSON CULLISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 S 9TH ST, STE 740
Mailing Address - Street 2:JEFFERSON DERMATOLOGY ASSOCIATES
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4408
Mailing Address - Country:US
Mailing Address - Phone:215-503-6680
Mailing Address - Fax:
Practice Address - Street 1:3521 SILVERSIDE RD STE 1L
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4900
Practice Address - Country:US
Practice Address - Phone:302-477-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303362207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery